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Deciaration ot Domicile and Citlzenship
TO THE STATE AND COUNTY TAX ASSESSOR, 2 ~ 6 2 3 9
Sl. lUC1E COUNTY, FlOR1~A:
This is my declarafion of ~om~ule and Citizenship in the State of Florida that 1 am filing this day in accordance and
~n conformity with Chapter 222, Section 222.17, Florida Statutes.
1 was formerly a legal resident of ; r~,~~ ~ . _ _ _ _ ~-l~y/-~~N
(City) (State)
and I resided at ~3 S' ~~L.. However I have changed my domi~ile
(Street a~d Numbe~)
to and am and have been a bona fide resident of the State of Florida since day of
_ ~~~-r~ ' , 19__:~ d, and I reside at ~j ~ ~ d _ _ - -
(Street and Number)
FORT PIERCE, SAINT LUCIE COUNTV, FLORIDA
and this statement is ro be taken as my declaration of citizenship, actuai legal residence and domicile in the State of Florida.
(Insert here any pertinent facts, such as sale of property or business, or relinquishment of employment
at former domicile, removal af family to new domicile, purchase of home, etc.)
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e 206239
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~ I FURTHER CERTIFY that I will comply with all other requirements of a legal resident of this State.
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~ I FURTHER CERTIFY that I have no intention to return to my former domicile, anc! I intend to remain in FORT
~ ~!ERCE, SAINT LUCIE COUNTY, FLORIDA, permanently.
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~ ,:,.~j~5~~~~IX~P~ wbxribed before me this / _ day of _ 19~/
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~ C1~ ~ COURT Notary Public
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~ gy' ~ • ~ ~ D.C_ My Commission expires _ -
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(To b~ ~xecut~d in dupliut~ and ori~inal ~il~d witi~ Cl~r{c Grcuit Court, ar~d dupliwte with T~x Ass~ssor.)
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